We look forward to our later years as a time for plenty of travel, reflection, playing with grandkids, volunteeringnot to mention spending our hard-earned retirement savings! Sadly, for too many older people, their "golden years" are a time of pain and despair. An estimated 18%-25% of elders need care for depression and related mental health disorders, including anxiety and schizophrenia. Few, however, find the help they need, and the problem is not a simple case of "having the blues" once in a while.
If left untreated, such mental health disorders can lead to suicide. People over age 65 make up 12% of the US population, yet the 65+ population accounts for 16% of suicide deathshigher than the rate in the general population. Studies show that up to 75% of older adults who commit suicide had visited a doctor within a month of their deaths.
One important reason older people experience depression is related to hormonal change. Depression also is a major symptom of low thyroid hormone levels, a nearly ubiquitous problem in the older population. Elderly depression is a problem for both men and women. However, since women outnumber men disproportionately after age 65, it's easy to misread the statistics and believe that older men don't get depressed.
In men, low testosterone levels and depression symptoms such as nervousness, inability to concentrate, and forgetfulness were documented as early as the 1940s, says Richard Cohen, MD, a hormone specialist in Massachusetts. "Scientists now know that testosterone affects brain chemistry, specifically the production and release of dopamine and serotonintwo important neurotransmitters that control human thought and emotion," he says. "There are literally millions of men who could benefit from knowing that low testosterone may be negatively affecting their moods and overall sense of well-being." In women, deficiencies in the hormones progesterone and estrogenboth of which decrease with menopausecan be linked to depression. Some researchers believe that an even bigger problem in both elderly men and women is a reduction in DHEAthe most abundant steroid hormone in the human body, and an important building block for testosterone and estrogen. Levels of DHEA in the elderly are the lowest of any age group. Research regarding the use of DHEA as an antidepressant is ongoing. A number of other physical causesmedications, loss of function due to arthritis, heart disease, osteoporosis, lack of physical activity, even dietary deficienciesalso can cause or contribute to elderly depression. In addition, depression can be situational, developing from isolation, financial worries, inability to get out into the community, loss of a loved one, retirement, or boredom.
Why Most Depression in Older People Remains Undiagnosed and Untreated Primary care physicians are generally not well-trained in recognizing depression in their elderly patients. Older patients tend to assume that symptoms such as sleep disturbances, mood changes, and loss (or increase) in appetite are simply a part of growing old. Many physicians accept such explanations for probable symptoms of depression rather than encourage the patients to undergo psychological tests. Research is currently being done to improve physician recognition and treatment of depression and suicidal symptoms in elderly patients. Programs have been implemented and evaluated at healthcare clinics, and results show that among elderly patients served, major depression improved and reported thoughts of suicide were reduced. Other studies and interventions funded by the National Institute of Mental Health (NIMH) focused on the relationship between other medical illnesses and depression, depression treatment for low-income older adults, physical function and depression, overcoming barriers to treatment for depression, and improving adherence to treatment for depression. Additional reasons for high rates of undiagnosed depression and mental illness among the elderly include the following:
In many cultures, mental illness carries a social stigma. Many administrators with tight budgets reduce services for the elderly. How to Tell If Someone Is Depressed Symptoms of depression are often mistaken for other illnesses or mere "signs of aging." It's important to watch for patterns, but if an older person you know exhibits even one of these symptoms for more than two weeks, he or she might benefit from a mental health evaluation: Acting more disoriented, confused, or easily agitated than usualStrong, repeated concerns about death and dyingAn unexplained change in behaviorA tendency to frequent arguments and "bad moods"Not taking medications, not eating properly, or not caring for personal hygieneAvoiding people; feelings of anxiety around peopleDrinking excessive amounts of alcoholFeeling pains that have no medical basisWandering around aimlesslySuspicions about other people, including friends and familyFeeling nervous or worried without a reasonFinding no pleasure in doing things he or she used to enjoyFeeling hopeless, worthless, or excessively guiltyFeeling that life is not worth livingProblems with sleepingFrequent crying How Friends and Family Can Help It's important to take a comprehensive approach," says Dr. Cohen. "Make sure they are eating nutritious food and taking a multivitamin and mineral supplement rich in B vitamins." Children and friends should encourage walks, he addsespecially in the morning sunas well as provide social stimulation.
Ask the elderly persons physician to re-assess the patients medicationsit's possible that some are counteracting, and may need to be changed or eliminated. Medication Fortunately, we live in an age when depression usually can be treated without hospitalization and/or invasive procedures. In mild to moderate cases, some people even get relief with St. John's Wort, an over-the-counter herbal supplement. People with major depression often respond well to antidepressant medication. Before taking an antidepressant drug, a physician will consider all aspects of the patient's health and prescribe the drug least likely to cause any serious side effects. Low initial doses are initially prescribed to allow the body to adjust to the medication slowly. In older adults it may take 6-12 weeks for a drug to produce noticeable results. Like many medications, antidepressants have side effects that sometimes restrict their use with older people. Side effects range from minor onessuch as a dry mouthto the more serioussuch as a drop in blood pressure. However, there are several drugs that are well-tolerated by older adults that may cause little or no side effects. Psychotherapy It is only recently that psychotherapy has been used as a primary treatment mode in older adults. Until now, there has been a historic bias against psychotherapy as a treatment for older people due in large part to Freud's belief that older people are too rigid to benefit from psychotherapy.
There are many different approaches to therapy. Often psychotherapy with older people is problem-oriented, focusing on helping people deal with immediate issues such as the loss of a loved one, a change in residence, or retirement. Others approaches can focus on making behavioral changes, such as learning to adopt new views on life or restructuring daily activities. Family therapy is also helpful in assisting older people and their children when working out unrealistic expectations, guilt, and unresolved issues that parents and children may have with each other. Research has found that cognitive-behavioral therapy is especially effective in elderly patients. Depression Can Be Successfully Treated in Elderly Patients Studies have found that approximately 80% of older adults with depression improve when they are treated with medication, psychotherapy, or a combination of the two (which researchers have shown is the most effective treatment method for elderly patients). Coexisting medical conditions also tend to improve when depression is treated. Depression is an illness that can be successfully conquered, especially in older people. RESOURCES: Administration on Aging
US Department of Health and Human Services http://www.aoa.dhhs.gov American Academy of Family Physicians http://www.aafp.org National Institutes of Health, Senior Health http://nihseniorhealth.gov National Institute of Mental Health http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm Last reviewed November 2007 by Theodor B. Rais, MD Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.